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HomeMy WebLinkAbout0123 BOG ROAD - Health 123 Bog_RO"t \\ F[Marstons Mills F 455 016 I / I l� 1 r I 1 ; t I i i 'i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.i;,l.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. WQ�� ry DATE: LI I Fill in please: 4. 0it,"1 1 APPLICANT'S YOUR NAME/S: �. C CI, ` t BUSINESS YOUR HOME ADDRESS: �' *- , �R TELEPHONE # Home Telephone Number '"7 -7 t; NAME OF CORPORATION • ' NAME OF NEW BUSINESS TYPE OF BUSINESS G S t IS THIS=A HOME OCCUPATIONS YES . NO ADDRESS OF:BUSINESS Y I'�iI MAP/PARCEL NUMBER (Assessing) born When starting a new business there are several things you must do'in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has beep infor of the mit requirements that pertain to this type of business. Authorized ture** COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: H zar ous Materials Inventory Sheet Checklist Date Physical Street Address-Check database to ensure it exists Working Phone Number Victual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) e4l)4 Storage Information -location of storage, how long is storage for? If none, note that. G �— Disposal Informati"whernd who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and plain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. TOWN OF BARNSTABLE Date: / g�/ TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: C�D`nWS+b&j- JA . T BUSINESS LOCATION: 6ayr\, UM t., INVENTORY MAILING ADDRESS: (I' q COX J G 1 y-L+s S ftj& kkk l0a.( L1 TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: . — (3 1 MSDS ON SITE? TYPE OF BUSINESS: INFORMATION / RECOMMENDATIO S: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) o� Diesel Fuel, kerosene,#2 heating oil Photochemicals (Developer) ❑ NEW ❑ USED Miscellaneous petroleum products: grease, lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicani4 Signature U Staff's Initials CERTIFICATE OF ANALYSIS Page: 1 S m'' Barnstable County Health Laboratory Report Prepared For: Report Dated: 3/20/2008 p A P Patricia Powers Order No.: G0845453 123 Bog Road Marstor_s Mills,MA 02648 Laboratory ID#: 0845453-01 Description: Water-Drinking Water Sample#: Samaling Location: 123 Bog Rd.Marstons Mills,MA Collected: 3/19/2008 i Collected by: P.Powers Map 045 Parcel 016-001 Received: 3/19/2008 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested Total Coliform Absent P/A 0 0 SM 9223B 3/19/2008 Water sample meets the recommended limits for drinking water of aii the above tested parameters. Approved By• (Lab D' tor) .fir' r\) i f'ta .:._ 'TA ND=Nane Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 1 9 , Barnstable County Health Laboratory rsnc '" Report Prepared For: Report Dated: 10/17/2007 Patricia Powers Order No.: G0743812 123 Bog Road Marstons Mills, MA 02648 Laboratory ID#: 0743812-01 Description: Water-Drinking Water Sample#: Sampling Location 123 Bog Rd.Marstons Mills,MA Collected: 10/16/2007 Collected by: P.Powers Map 045 Parcel 016-001 Received: 10/16/2007 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 10/16/2007 Copper ND mg/L 0.10 1.3 SM3111B 10/17/2007 Iron 0.24 mg/L 0.10 0.3 SM 3111B 10/17/2007 Sodium 9.9 mg/L 1.0 20 SM 3111B 10/17/2007 Total Coliform Present P/A 0 0 SM9223 10/16/2007 Conductance 97 umohs/cm 2.0 EPA 120.1 10/16/2007 pH 6.3 pH-units 0 SM 4500 H-B 10/16/2007 Recommended maximum contamination level exceeded due to Colijorm Bacteria. Retesting is recommended Approved By: (L Director) cz 517 a- C.f'i tom; ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Town of Barnstable Regulatory Services Thomas F. Geiler,Director * iARNSTABLE, '& A�Og Public Health Division { lFn rna+ Thomas McKean;Director . 200 Main Street,Hyannis,MA 02601 Office:. 508-862-4644 '\ Fax 508-790-6304 Installer & Designer Certification Form ¢ s Date: 8-- y- a6 Sewage Permit# Zoo -33 o Assessor's Map\Parcel\ Designer: W EU re� 4 C/.4 7"ES' Installer: (2 L J 15 s 1(u)G Address: . 164�f- sv �Y �a�� Address: C�KTt /F U!LLE W EbT7V.44 w A ►)-I-�w On Z�{- 0 6 .C, was issued a permit to install a (date) (installer) septic system at . /Z3 g o o /Qd AA . based on a design drawn by (address) 3; rg---< e�4�� ,(�/� / C• .fr,Q/,�dated ,-/8-Ca (designer) 1Z I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. a o (Installer's Signa re) o BARAMAN ���'� STRUCTURAL NO 36595 ( esigner's Signatu e) (Affix Des i ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 03-09-06.doe z. TOWN OF BARNSTABLE LOCATION 123 �QG .4 a,Q,4' SEWAGE # Zoo VII.iSAGE I, 49.%7a.,) ad4L = ASSESSOR'S MAP & LOT YS-•,��—/ INSTALLER'S NAME&PHONE NO. g R,�,;) C. vllsG SEPTIC TANK CAPACITY Aron =s?" LEACHING FACILITY: (type) 3-Sbo G4JZ&4a;r.6 c size) J-? X3 NO. OF BEDROOMS a BUILDER OR OWNER�7-R IC�;� 1�^ ►�,ps PERMITDATE: Z�/- e,< COMPLIANCE DATE: F— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by To a IL LOCATION SEWAGE PERMIT NO. 4'1 .a t3pc F 1 s Z f •VILLAGE s'7-aya I INST: A LLER'S NAME i ADDRESS ds B U I L D E R OR OWNER` p/ r rG DAT PERMIT ISSUED � DATE COMPLIANCE ISSUED & �. �,� - 25 i Sox W ELL 4. Fee THE COMMONWEALTH OF MASSACHUSETTS `! / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppIication for Bigpogal *pgtem Congtruction Permit Application is hereby made for a Permit to Construct(4,-�or Repair(man On-site Sewage Disposal System at: Location Address or Lot No. 0/I-3 Owner's Name,Address and Tel.No. ol PAr2tc►A PoWCAX Assessor's Map/Parcel /J/s 6' / Z3,8 O 6 k of,6 14A4A 5Tb4(S UA t / Installer's Name,Address,and Tel.No. .SC 8 7700-0 yy$1 Designer's Name,Address and Tel.Np. 4Vb8 6?s7j-o 73_S- Q k A,J c. I<Ls's�f ' G w�-IL_=A f 4 ss o cf,4 t�- 9'1 TWA) AkacK wEsr MA wok /6ysF.11�o� &d/ 09,,vt4t4Vd14C_ Type of Building: Dwelling No.of Bedrooms_� Garbage Grinder(Kid Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1 D gallons per day. Calculated daily flow Y-5-;z=2 gallons. Plan Date —/e=n(, Number of sheets Revision Date Title Description of Soil O /? C r' . 45,C_ g.4,T Nature of Repairs or Alterations(Answer when applicable) — Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has b ed oard of Heal Sig ed ' Date Application Approved by Date 7 Application Disapproved for the following reasons Permit No. r ��lJ Date Issued At7N �n - �•„� Fee THE COMMONWEALTH�OF MASSACHUSETTS -TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION O 1 MASSACHUSETTS - 01pprication for Mizpooal *p5tem Congtructioh Permit 1 Application is hereby made for a Permit to Construct or Repair 'an On-site Sewage Disposal System at: Location Address or Lot`No �� Owner's Name,Address and Tel.No. �� x vf1 �t]�f+clt.,l J :C,wF_ -t Assessor's Map/Parcel• �/ l /�/l r7 )/ '!i o,4 Q (•l,'tAfAk:. Y(J✓l��'i.�-t`IlC,s... 6talller's Name,Address,and Tel.No. c 7c Designer's Name,+�Address and Tel-..No. Scj r't! c? t �C l.� /� Y y�C.3 r��l•r(:..� tiJ Tz.1.0 K4.r, lsYf�C! ll `r yA,N �,ct � t.tfl� ��J r� .v;C=A,v�t[� Type of Building: Dwelling No.of Bedrooms y Garbage Grinder W p) Other Type of Building ' No.of Persons Showers( ) Cafeteria O ' Other Fixles f Design Flow i i n gallons per day. Calculated daily flow .,— : gallons. Plan Date Number of sheets Revision Date Title Description of Soil U r_ !" Nature of Repairs or Alterations(Answer when applicable) i , I ITT4 4 4t.r c r . n» ' Date last inspected: E Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system . in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has be ed oard of Health: w Sig:ed � Dategp Application Approved by Date ' Application Disapproved for the following reasons Permit No. _ Date Issued • E THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed or repaired/replaced(H-on by f Installer , C.. at ',' _� r-'r sT. r ' r- has been constructe in accc)r ance with the provisio s oYide 5 and the for Disposal System Constru on t No. La 6 6 dated_ ` Date Inspectors t J j , THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. --- 4 P- - -----------------.--------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwi!6pogal. *p5tem Congtruction Permit Permission is hereby granted to c� •.<to construct( )repair( 4.-)an On-site Sewage.System located at.No.# 10-723 j-r WT + Street and as described in the above Application for Di sposal.System Construction Permit.'Ace& 3 � ? No. Date The applicant recognizes his/her duty to comply with Title 5 and the followi ng local provisions or special conditions. All construction must com 1 t d within three years of the date bel Date: Approv a Board of Health .. 1 ' 3 Town of Barnstable h 3 Department of Health,Safety,and Environmental Services j Public Health Division Date 367 Main Street,Ilyannis MA 02601 eAkxcrreBIA : y� 9 �� Time. Fee Pd.lFGMII�� Date Scheduled / Soil Suitability Assessment for ►sewage Dis osal Performed By: Witnessed By:: .LOCATION & GENERAL INFORMATION Location Address/� �a� �,��> , Owner's Name , �r z7 �Li'/L� Address �f �/'��OC���/� Assessor's Map/Parcel: �j "16 m/ _ a. Engineer's Name G�,p� NEW CONSTRUCTION REPAIR °eY1J:v{� Telephone H Land Usc �'is1�QJt�� ���— Slopes(%) % Surface Stones IV _ Distances from: Open Water Body ttY R Possible Wet Area R Drinking Water Well R Drainage Way R Property Line R Other R SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) a Z_. Parent material(geologic) �A�✓CZ. Depth to Bedrock VIA IA Depth to Groundwater: Standing Water in Ilole: 77011IQ, Weeping from Pit Face Estimated Seasonal High Groundwater 11! lr7 TC OETERMINATIOty FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment R• Index Well N Reading Date:_ Index Well level. Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date 12 Time f a Observation I Tole# Time at 9" Depth of Perc pp 'Time at 6" Start Pre-soak Time @ I •� Time(9"-6") End Pre-soak t C Rate Min./Inch Site Suitability Assessment: Site Passed V— Site Failed: Additional Testing Needed(YIN) Original: Public Ilealth Division Observation Hole Data To Be Completed on Back Copy: Applicant DEEP OBSERVATION HOLE LOG Hole# Dep1h from Soil I lorizon Soil•texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % l c s n DEEP OBSERVATION HOLE LOG Hole# : Depth from I Soil llorizon I Soil Texture i Soil Color Soil Other Surface(in.) Mottling (Str:ctme,Stones,Boulderes. Consistency.° Gravel) DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency. Gravel) nr DEEP OBSERVATION HOLE LOG Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Of Yes Within 100 year flood boundary No 9/ Yes Depth of Naturals Occurring Pervious Material Does at least four feet of naturally occurring,pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection an1that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. y Signature 0 Date -2 117 06 RECEIVED COMMONWEALTH OF MASSACHUSETTS JUL 15 2003 EXECUTIVE OFFICE OF ENVIRONMEN`PAL AFFAIR T N OF BARNSTABLE DEPARTMENT OF ENVIRONMENTAL i ROTECTI EALTH DEPT. d d� FAILED INSPECTIONOPPP c eW o,M Sye TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION `( M Property Address: 123 BOG RD MARSTONS MILLS 02648 �y S 1\p cow Owner's Name: LAURETTE SMITH Owner's Address: SAME 1 Date of Inspection: 6/23/03 Name of Inspector: (please print) JOHN GRAC1, INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally lasses _ Needs Furt a Evaluation by the Local Approving Authority X Fails Inspector's Signature: Date: 6/23/03 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this ins on. If the system is a shared system or has a design, flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the systetq owner and copies sent to the buyer, if applicable,and the approving;authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN D-BOX IS OVER PIPE-SOIL IN AREA OF PIT PROBED WET-SAS IS PAST THE EFFECTIVE DEPTH OFLEACHING. SYSTEM NEEDS TO BE UPGRADED. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Tit1P S IncnPrtinn Form F/l snnnn 1 i Page 2 of II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not fo ind any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN D-BOX IS OVER PIPE-SOIL IN AREA OF PIT PROBED WET-SAS IS PAST THE EFFECTIVE DEPTH OFLEACHING. SYSTEM NEEDS TO BE UPGRADED. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or itributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 1.5 YRS AGO INFO FROM OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter read_ngs, if available(last 2 years usage(gpd)): Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary was-le discharged to the Title 5 system(yes or no): NO Water meter read'ngs, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: 1.5 YRS AGO INFO FROM OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alte-native technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1985 BY ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 BUILDIN EWER G S (locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage,etc.): WELL WATER LOCATED OUT FRONT AT THE BOTTOM OF DRIVE WAY- 100+FEET AWAY FROM PIT SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8'6" H 5' 7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): LIQUID LEVEL:WAS OVER TEE IN SEPTIC TANK. SAS IS PAST THE EFFECTIVE DEPTH OF LEACHING. COMPONENTS TO TANK ARE STRUCTURALLY SOUND. GREASE TRAP: —(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n./a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grace: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVER PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a I R __ I Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING-LIQUID LEVEL WAS OVER PIPE IN TANK AND D-BOX-PIT IS SATURATED AND NEEDS TO BE UPGRADED. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a A Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contended) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �edL fo A IcI� �l f5 At SN Pp IL QN 4 Page~I I of 1 1 l OFFICIAL INSPECTION .FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 123 BOG RD MARSTONS MILLS 02648 Owner: LAURETTE SMITH Date of Inspection: 6/23/03 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system'design plans on record-if checked, date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY AUGER- 12+ FEET r - /,') 3 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................OF..........................................._........... Appliration for Uiipusal Works Tonotrnrtion ramit I" �,�01's—, Application is hereby made for ermit to ct ( ✓S or Repair ( ) an Individual Sewage Disposal System at: 1 1.3 0& -��.��.... ���r�._.. .j��...�IA.LIs�- -•-•......--•-•-••••--•.............•.--•-••...... ---...._---•-••••..-•••--•--•--•- -•--•--• Location- dress or Lot No. - Ow er Address Installer Address ,( _ r- Pq U Type of Building Size Lot./3��_.ft_L .c Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------•-- .._... W. Design Flow...........................0__�...........gallons per person per day. Total daily flow.... ...............................gallons. 04 Septic Tank—Liquid capacityisAo..gallons Length.la`4". Width-_- ' Diameter---_- ..... Depth.jC!'.... W W Disposal Trench—No..................... Width............. Total Length.................... Total leaching area...................sq. ft. Seepage Pit No........./.......... Diameter.._...Via........ Depth below inlet....... ._.._____. Total leaching area...K4?1....sq. ft. Z Other Distribution box (✓S Dosing tank ( ) Percolation Test Results Performed by....,4kAn-Ge¢p�.._ i�Jlfi .-.__.�!�____ Date_. \-Test Pit No. I.......Z.....minutes per inch Depth of Test Pit.....1.Z......... Depth to ground water_4C%1%_i t.--. 0, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--••-•-••-••--•-•--•••-•-••-••------••---•----•--•--•. .....-•...............•---------•-.................................................................. 0 Description of Soil....... Tarr----••--....r.d­.....Go.v2 --� 2-3oAl x W VNature of Repairs or Alterations—Answer when applicable............................................................................................... ----•---•-•-----------------•-------------•-•------------•-----.....---------------•-----------..............----------------------------------•---------------•-•----------------------...........•-•-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with. the provisions of TITI.I 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. c Signed v__ �l �� to A plication Approved By------------•. . • .•----- ..--•..... ......... `-- Application Disapproved for the o owing reasons---------------------------------------------------------------------------------•-----------------......._..._.. --•------•------•-------------------------------------------•--------.....--------•------._.....---------•-------------------••-•-----------•-------•----•-•-•----------••-•----------••-••--......_:__. Date Permit No... _.s�..�.. ........... Issued Date No....................... Fmc ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ..............................OF................ for` Disposal Works Tonstrurt. ion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: . . .. .......... .. . ........- ..... - . .... Location Address or Lot No- .............................................................................................. ............................................................................................-.-.-.-.-.- Owner Address $4 .................................................................................................. .................................................................................................. Installer Address Type of Building Size Lot.11_4,_Ae.Sq. feet Dwelling—No. of Bedrooms....3.....................................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures ............................. Design Flow........................... ...........gallons per person per day. Total daily flow.._.33P................. ............gallons. P4, Septic Tank—Liquid capacityZIE9.9.-gallons Length__Z�2'.!�". Width__- Diameter_______7=... Depth..�i.'if" .......... Disposal Trench—No....................... Width.--......._.__...... Total Length....._............._ Total leaching area....................sq. ft. Seepage Pit No:_-_-___- .......... Diameter...._.Z-:2........ Depth below inlet......'_....... Total leaching area...;?.6.7....sq. ft. Z Other Distribution box (v') Dosing tank Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1.......?-=.....minutes per inch Depth of Test Pit------4?.......... Depth to ground water. 3..t.--- fZq Test Pit No. 2................minutes per inch Depth of Test-Pit.__.........._..._.. Depth to ground water.___.....__..__.....___. ................................................................................................................................................ .............. 0 Description of Soil----. 14" , W .....................................................Z........ ';-�...... ........................................................... . .... U ....................... ........................................................................................................................................................................... ................................................................................................................................................................................ 7-----*--------"......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ................................................................................................................... ................................... .................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE .5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. f...............) Signed........... ................. ......7. 1. Application Approved By................. . ............... ....... ... . ...... .............1 t------- .............. ........... Date Application Disapproved for the f 11 wing reasons:................................................................................................................. . ............................................................................................................................................................. ........................................... 2 . Date PermitNo._. --- ...... 3 Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................................. e (Irrfifirate of Toutphaurr THIS IS TO CERTIFY, That the individual Sewage Disposal System constructed or Repaired by.•............... ............. .......................n................0......................................................... Installer I............... . at:............ ...... - 0 ......X11............... ... ......... ........... has been i st,led in accordance with the provisions of TIT IZ�_5 of The State Sanitary Code as deperibjAja the C application for Disposal Works Construction Permit No....��S..... _(Z.......... dated___________ ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUAR NTEE THAT THE SYSTEM WILL.NNCTION SATISFACTORY. ' —1 .DATE.. ......XV.... .............................. Inspector........ . ........................................... ....... ......... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF............................................................. No. 5-63� ...................... FEE.... ............. rks (go, str ion omit Vj . Z" Permission is hereby gran M�V 1—Z granted.............!t...................................0.............................................. to Construct or Repair an Individual Sewage Disposal System at S No..X....../,.o ......... .......................... ....t.•--'a.................................... Street --- TS- q as shown on,the application for Disposal Works Construction Permit No.. 3 IDated.-------- ---------*------------------- ..............................A Ali ............................. DATE................... .............. Board of Health ------------------------ FORM 1255 A. M. SULKIN, INC., BOSTON . 14 I p(4i r � " 1 - { oe i I. 11.0 5 1 rO dtopm ,7 4 Tv i ,500 M L ¢� Sc;Ct+[,e ff1 ' - r �q !S 7 §. l 9. -F�� k ; �.Q r « ���C { .! .. } , �V•, 1 ! .. 1 I._ �t t P'G!bMF cctCe /" t ro, { 4-4-}j i G Cie f t Ma .� t�uriti/tad 02601: { i , x { .C'c�$ r,�. lj9arafiona. l��,Lls, I r e.�ng4 a �howrt orir-a -p.lan ac Al ois is�i fh a zd dciz lwl8/8f ; ,4 4 , ' f 'ff Xe lt e �evafi orts mown awe Gaffed on c ar leA 6"&.6 a-td'o > 4121 o4l opt l'6 2.i inin. p et FjM S ,R sr oy • � r " ) t � � � L ; t; o� Vd{L�IAtVI �� i s 1 t � a I § r 1 r 1 rFA 01� �. Nb 8995�Q �a Y L'SfjONA� _!... i- � 11 _i - i t t •, ��( s I I � f � i § T , F a'fl ��ii{ 1 3 i i i �t N ~ NOTE: EXTEND COVEK5 OF TEST DOLE LOG SEPTIC TANK TO WITHIN DATE: _ 7-12-©cam 6° OF FINISH GRADE PIPE TO BE LAID LEVEL TEST BY:`- �-t', C� 'LOU��Ci ✓ Cs"� W U � FOR 2' OUT OF DI5TRIEUTION WITNESS:- ;p, n1 a BOX PERC RATE: Q " LAYER OF 3/8" PEASTD_1NE_ `y ` `a- 4"SCH 40 PVC PIPE OVER 3/4" - I I/2" DOUBLE v1 WA5HED STONE ALL AROUND y TEST HOLE # I H TE5T HOLE # 2 S X C p 3J'd D 3,p I Dcv S T.O.F. L d EL.✓��3� ^ TOP EL. O33.c�a 7 IN OUTLET TEE APPLE 2 BOTTOM EL. �O,7;-3 J 3Z.pa a w - 6" STONE BASE - Q �# lSoea GALLON PRECAST SEPTIC TANK / LOCATION MAP //,oZ' SEPTIC 5Y5TEM PROFILE za.s /yy 25,a Z l/ N 0 DESIGN DATA DAILY FLOW: (-e ) BEDROOMS x I 10 GPD y5�� GPD M SEPTIC TANK: fIlo GPD x 200% c> GPD 1 I '4 U5E: GAB- �, SOIL AB50KFTION SYSTEM: i n US E: 3 S x'8, s- CAPACITY: I � SIDEWALL AREA:_ 9.3 Z X 75/ 37,C� BOTTOM AREA:-:/3 o GENERAL NOTES 1 . CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION \�..- A N OF A 32- TILITIES, ABOVE UNDERGROUND, PKIORTO Y CAVATION OK CONSTRUCTION. -,�,,,,� 2. 5 IC SYSTEM IS TO BE INSTALLED IN COMPLIANCE j moo. WITH 10 CMK 1 5.00: TITLE V. :3. TI,1' PLAN IS NOT TO BE USED FOR PROPERTY LINE ii DETE (NATION. 4. L DISTURBED AKEA5 ARE TO BE LOAMED * SEEDED. 5. ONTKACTOK TO PROVIDE 48 HOUR NOTICE FOR ANY fz 21q, / P UIKED INSPECTIONS*. THIS SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. -- 5ITE SEWAGE PLAN LOCATION:-/Z3 �t5 �,�'-� /-f.�?�sTn.vs /GG.OF �y1� CLIENT: h` STEVENr-Cy� f C� f1V SCALE: 4 DATE: DRAWN BY: MB DANIEL E. d� f I "u f ar B AN ..• }• iIF '"' JOB NUMBER: 35 J 1 s •••� _. REVISION: SHEET NUMBER: r� t FJ� WELLED A550CIATE5 �•+�5• �„ 11 —d IG45 FALMOUTH KD., SUITE 4C P.O. BOX 417 CENTEKVILLE, MA 02632 2 WINDY WAY, #232 NANTUCKET, MA 02554 TEL: (506) 775-0735 — FAX: (506) 775-0735 EMAIL: tr;swellerecomcast.net PROFESSIONAL ENGINEERS LAND SURVEYORS " I I_ - - T - - I I I I